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0 <br />C <br />San Joaquin County <br />Environmental Health Department <br />600 East Main Street, Stockton, CA 95202-3029 <br />(209) 468-3449 Fax: (209) 468-3433 Web: www.sjgov.org/ehd <br />Well Permit Application <br />NON-REFUNDABLE PERMIT EXPIRES 1 YEAR FROM DATE ISSUED <br />SITE <br />MITIGATION <br />UNIT IV <br />Application is hereby made to San Joaquin County for a permit to construct andlor install the work described. This application is made in compliance with San <br />Joaquin County Development Title, Chapter 9-1115.3 and the Standards of San Joaquin County Environmental Health Department. <br />Assessors <br />WELL Location 3�'t� ' ' ' ( Cross Street �� city 1v Zip Parcel# i�!L•�I <br />PROPERTY <br />c <br />nwnar ig � <br />Phone#-Lt�((��' <br />'t c tri 1t„ a jA, �- c c u <br />C-57 Contractor i°J ' - c Address City Zip Lie# Phone# cad' e r i7� 3 <br />iw <br />�t2`l VAAst- t 5Z'J <br />Consultant t Sub Cntr Mt � t � t1\ Address 11104,G Address S Li s 4(_.�3L� _ _City �� Lic# Ii�� moi^ Phone# V <br />0 . I . 2-3 <br />w �) t+ t to - <br />GIS Coordinates: X -12 C '� L-11 Y `5 V Stie , Township i _ Range l l? Section <br />WORK TO BE PERFORMED: <br />EW WELL 1 BORING (CPT, GEOPROBE, HYDROPUNCH. HAND -AUGER, OTHER*) 0 DESTRUCTION (choose type below) <br />a SOIL BORING # © OVER -BORE. DIAMETER <br />WELL # 0 PRESSURE GROUT <br />other i 11 1(AcI GROUT SPFC.IFICA`TIIONS <br />COMMENTS: , ' f , i. i1+ `� �1 /1 J <br />TYPE OF WELL INSTALLATION TYPE CONSTRUCTION SPECIFICATIONS <br />jl MONITORING )QiOLLOW STEM DIA. OF BOREHOLE 0 MULTIPLE CASINGS p MULTI-LEVEL WELL CASING DIA: _ <br />a EXTRACTION u AIR HAMMERIDRIVEN CASING THICKNESS TYPE OF CASING: 0 STEEL a PVC OTHER: ' <br />U VAPOR MUD ROTARY DEPTH OF GROUT SEAL TREMIE TYPE TO BE USED: GAUGERS 0 HOSE <br />p AIR SPARGEI OZONE © PUSH POINT (GP or CPT)GROUT SEAL PUMPED: p Yes a No (NOTE: tMAXIMyU,M FREE -FALL DEPTH IS 30') <br />b�i.iL�iar, <br />a SOIL BORING (] HAND AUGER GROUT SPECIFICATIONS Y� V <br />�bTHER: Vel*Q OTHER APPROX. BORING DEPTH_ +� a BOLTED TRAFFIC BOX or STOVE PIPE <br />ii CONDUCTOR CASING PROPOSED (if Y i, list specifications in comment section) <br />COMMENTS: <br />NOTE: OFFSITE BORINGS REQUIRE ACCESS AGREEMENT OR ENCROACHMENT PERMITS. <br />48 WORKING HOURS NOTICE REQUIRED FOR INSPECTIONS. <br />I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin <br />County Ord' nan s R les and Regulations, and all applicable California State Laws. <br />Signed x 7%Title/Company 14SSGCv`:,' , til +t-�� d.��✓u <br />Print Name `' � ...3'+Y�l'Y- �-��� Date +�i` i Cf <br />DEPARTMENT USE ONLY PMME <br />SITE MAP IN UNIT IV FILE, ADDRESS: <br />WORK PLAN DATED: / 008 <br />Application Accepted By��6� > Date Issued �� OB P9AIN COUNTY <br />Grout Inspection By e Date lP/��®$ Final inspection By �� ate A <br />Destruction Inspection By Date HEALTH DEPAK I MCS <br />COMMENTS I CONDITIONS: <br />ACCOUNTING ONLY: AID# FAC# <br />PE CODES <br />FEE INFO AMOUNT REMITTED <br />CHECK # REC'D BY <br />DATE PERMIT f SERVICE REQUEST # <br />INVOICE <br />C-57__._ WC -WAIVER_ C-57 Letter of Authorization to sign permit_ Encroachment doc_ <br />END 29-02-001 WEB <br />9/11/2007 <br />